Internal medicine resident Wilmington, Delaware, United States
Disclosure(s):
Bryce N. Grohol, DO, PharmD: No financial relationships to disclose
Background: In Graves Disease (GD), over-activation of thyroid stimulating hormone (TSH)-receptors significantly increases thyroid production which can result in thyroid storm. 6% of thyroid storm cases go on to develop heart failure with even smaller subsets progressing to cardiogenic shock (CS). Mortality is as high as 30% due to diagnostic difficulties.
Methods: A 47-year-old male with a history of GD nonadherent to therapy presented with nausea and vomiting. He was tachycardic to the 200s and electrocardiogram showed atrial fibrillation. TSH was undetectable with significantly elevated free T4 and lactate. He was intubated and admitted to the medical intensive care unit with thyroid storm. An echocardiogram was completed showing severely reduced ejection fraction with biventricular failure. He was transferred to the cardiac intensive care unit where he was found to have a cardiac index of 1.2 and worsening end-organ markers. Dobutamine was started without improvement, and he was upgraded to an impella CP. Full workup including left heart catheterization was unremarkable. He was diagnosed with tachycardia-induced CS due to thyroid storm. He was weaned from his impella and started on metoprolol tartrate before being discharged with endocrinology follow-up.
Outcome: The diagnosis of thyrotoxicosis-induced CS comes after ruling out other causes such as cardiac ischemia. He was treated with an impella CP, however there is minimal data with the use of mechanical support in CS secondary to hyperthyroidism. Management of the underlying thyroid dysfunction is paramount once clinical stability is achieved.
Conclusion: Thyroid storm-induced cardiomyopathy is a rare but serious complication of GD. Prompt diagnosis and treatment can help prevent decompensation to CS. Further study is needed to guide use of inotropic and mechanical support such as impella CP in these patients.
